March 19, 2010

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Anthem Blue Cross and Blue Shield of Wisconsin – Lumenos Health Incentive Account Plus Plan 1 – WISCONSIN

A comparison of the Lumenos Health Incentive Account Plus Plan 1 offered by Anthem Blue Cross and Blue Shield of Wisconsin is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Lumenos Health Incentive Account Plus Plan 1 Application Lumenos Health Incentive Account Plus Plan 1 Application
Brochure Lumenos Health Incentive Account Plus Plan 1 Brochure Lumenos Health Incentive Account Plus Plan 1 Brochure
Copay N/A N/A
Office Visit Subject to deductible and coinsurance. Subject to deductible and coinsurance.
Deductible see brochure see brochure
Coinsurance 100% 70%
Coinsurance Limit see brochure see brochure
Out-of-Pocket Maximum see brochure see brochure
Lifetime Maximum Unlimited Unlimited
Prescription Drugs
  • Retail: 30-day supply.
  • Mail service: 90-day supply.
  • Subject to deductible and coinsurance.
    		•
  • Retail: 30-day supply.
  • Mail service: 90-day supply.
  • Subject to deductible and coinsurance.
    		•
    Emergency Room
  • 100% after deductible
  • Network and Non-network deductibles are separate and don not accumulate towards each other.
    		•
  • 100% after deductible
  • Network and Non-network deductibles are separate and don not accumulate towards each other.
    		•
    Adult Preventative Care 100% covered, not subject to deductible. Subject to deductible and coinsurance.
    Child Preventative Care 100% covered, not subject to deductible. Subject to deductible and coinsurance.
    Lab / X-Ray Subject to deductible and coinsurance. Subject to deductible and coinsurance.
    Maternity Optional Rider Optional Rider
    Physical Therapy
  • Subject to deductible and coinsurance.
  • 20 maximum visits per benefit period for network and non-network combined.
    		•
  • Subject to deductible and coinsurance.
  • 20 maximum visits per benefit period for network and non-network combined.
    		•
    Skilled Nursing see brochure see brochure
    Home Health Care
  • Subject to deductible and coinsurance.
  • 40 maximum visits per benefit period for network and non-network combined.
    		•
  • Subject to deductible and coinsurance.
  • 40 maximum visits per benefit period for network and non-network combined.
    		•
    Mental Health Not covered Not covered
    Hospital Care Subject to deductible and coinsurance. Subject to deductible and coinsurance.
    Optional Benefits Maternity Maternity